HomeMy WebLinkAbout03-15-13
1 1505610101
-1 REV-1500 Ex t°1-1°' '
OFFICIAL USE ONLY
PA Department of Revenue pennsylvania
Bureau of Individual Taxes DE-TMEMTOREVENIE County Code Year File Number
PO BOX 28o6oi INHERITANCE TAX RETURN I D
Harrisburg, PA 17128-o6o1 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
20 2~d Sy-65 06~ 6Zv12 pZZ21 X32
Decedent's Last Name Suffix Decedent's First Name MI
tfNEY THOMAS
(If Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Nnme Suffix Spouse's First Name MI
Spouse's Social Security Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
® 1. Original Return O 2. Supplemental Return O 3. Remainder Return (date of death
prior to 12-13-82)
O 4. Limited Estate O 4a. Future Interest Compromise (date of Q 5. Federal Estate Tax Return Required
death after 12-12-82)
6. Decedent Died Testate O 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes
(Attach Copy of Will) (Attach Copy of Trust)
O 9. Litigation Proceeds Received Q 10. Spousal Poverty Credit (date of death O 11. Election to tax under Sec. 9113(A)
between 12-31-91 and 1-1-95) (Attach Sch. O)
CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
KENNFTN F LEWD S FsQ L343/3~
REGISTE"F VYIIWS E ONLY
(D M
C>
First line of address C-> C~/a
i I o I ~D NTH FRS NT sT
(n Aa
Second line of address O '
c a -rt
City or Post Off ice State ZIP Code 7 CDA►TE P,ILEI$ i
2G o~
Correspondent's e-mail address: LP~,UIS~S~ kG~~pt~I/rflA.st/)~f
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief,
it is true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge.
S G ATURE OF PFD N RESPONSIBLE FOR FILING RETURN DATE
ADDRESS CS/
I QS Lh~ `r /hY! S /~J' J
SIGNAT RE F P PARER OTHE THAN REP ESENTATIVE DATE
ADDR
pf
Di+ 1V1 4h~ A, S)-19 l /lV z
PLEASE USE ORIGINAL FORM ONLY
Side 1
1505610101 1505610101 J
1505610105
REV-1500 EX
Decedent's Social Security Number
O t'I ~ ~ G
q 2- 2
Decedent's Name: -M6Ing ~}fNty
RECAPITULATION
1. Real Estate (Schedule A) 1. V . V
2. Stocks and Bonds (Schedule B) 2. D • O
3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) 3. D • C
4. Mortgages and Notes Receivable (Schedule D) 4. • li
5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)....... 5. 0 Z i •
6. Jointly Owned Property (Schedule F) p Separate Billing Requested 6. D • D G
R
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G) Separate Billing Requested........ 7. Z_ 3 • /
8. Total Gross Assets (total Lines 1 through 7) 8. 0-5
7 Z ~ • 1 I
9. Funeral Expenses and Administrative Costs (Schedule H) 9. j y- • 0 ~j
10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule 1) 10. 5 8
11. Total Deductions (total Lines 9 and 10) 11. 2-! 5 2 7 . ++5 +
12. Net Value of Estate (Line 8 minus Line 11) 12. D Z • J
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which ~p n
an election to tax has not been made (Schedule J) 13. ® it W 0 • L' G
14. Net Value Subject to Tax (Line 12 minus Line 13) 14. Z L
TAX CALCULATION - SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate, or
transfers under Sec. 9116
(a)(1.2) X .0- 15.
16. Amount of Line 14 taxable
at lineal rate X .0 _ • 16. •
17. Amount of Line 14 taxable
at sibling rate X .12 17. •
18. Amount of Line 14 taxable / •
at collateral rate X .15 ~y 18• 2-04 19. TAX DUE .........................................................19. -45
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O
Side 2
1505610105 1505610105
REV-1500 EX Page 3 File Number
Decedent's Complete Address:
DECEDENT'S NAME
om s r a~~ 4/I
STREETADDR SS - - -
1 Soo gild'? e Sf - - - - - - -
CITY /UA reN/ /",✓LII~I - STAT ZIP
Ft 0 Z /l/S
Tax Payments and Credits:
1. Tax Due (Page 2, Line 19) (1) ~j z04, t//
65
2. Credits/Payments 1
A. Prior Payments _
B. Discount
Total Credits (A+ B) (2) 0, 0 G
3. Interest
(3) 0,00
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Fill in oval on Page 2, Line 20 to request a refund. (4)
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) /4-►
Make check payable to: REGISTER OF WILLS, AGENT.
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes No
a. retain the use or income of the property transferred; ❑ K
b. retain the right to designate who shall use the property transferred or its income; ❑
c. retain a reversionary interest; or ❑
d. receive the promise for life of either payments, benefits or care? ❑
2. If death occurred after Dec. 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration? ❑
3. Did decedent own an "in trust for" or payable-upon-death bank account or security at his or her death? ❑
4. Did decedent own an individual retirement account, annuity or other non-probate property, which
contains a beneficiary designation? . ❑
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
may.:..
For dates of death on or after July 1, 1994, and before Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is
3 percent [72 P.S. §9116 (a) (1.1) (i)].
For dates of death on or after Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent
[72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and
filing a tax return are still applicable even if the surviving spouse is the only beneficiary.
For dates of death on or after July 1, 2000:
• The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent, an
adoptive parent or a stepparent of the child is 0 percent [72 P.S. §9116(a)(1.2)].
• The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent, except as noted in
72 P.S. §9116(1.2) [72 P.S. §9116(a)(1)].
• The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent [72 P.S. §9116(a)(1.3)]. A sibling is defined, under
Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption.
REV-1508 EX+ (i1-io)
i Pennsylvania SCHEDULE E
DEPARTMENT OF REVENUE CASH, BANK DEPOSITS & MISC.
INHERITANCE TAX RETURN
RESIDENT DECEDENT PERSONAL PROPERTY
ESTATE OF:. FILE NUMBER:
]ROW/1s 4 f ASY 2,1-1Z-6W'7
Include the proceeds of litigation and the date the proceeds were received by the estate.
All property jointly owned with right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER DESCRIPTION OF VALUE E DATE
DEATH
n~, 9851 y3 Sys (A 7" c1~se-a~~ e a IT 9 Q 2
Penn i~~ l Life mss, (P<o6eeds 5*1?7 a ed ; 5
Z~ t q, 653 `5
31 Pfimpql J,` D5U,4u06t (Pr (WS Sf4N*hk66dd) 1)11907 T U011
Fetid 6kfma~Adid) 6100
k Aud"'
~iq
~T~ i~(~Sq~S a A ~~11 r a~e o~~e1~?e W #alx?'5 b c0k)
~J ~ DD
(6~f ~
71 ~
so 6J Z,
kv`ces
q, y
TOTAL (Also enter on Line 5, Recapitulation) $ U Z f g
If more space is needed, use additional sheets of paper of the same size.
REV-1510 EX+ (08-09)
pennsylvania SCHEDULE G
DEPARTMENT OF REVENUE INTER-VIVOS TRANSFERS AND
INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY
RESIDENT DECEDENT
ESTATE OF-
j~~si FILE NUMBER
This schedule must be completed and filed if the answer to any of questions 1 through 4 on page three of the REV-1500 is yes.
ITEM DESCRIPTION OF PROPERTY
INCLUDE THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND DATE OF DEATH % OF DECD'S EXCLUSION TAXABLE
NUMBER THE DATE OF TRANSFER. ATTACH A COPY OF THE DEED FOR REAL ESTATE. VALUE OF ASSET INTEREST (IF APPLICABLE) VALUE
1. F~ ~el;~y n~es~~ a~zc ZZ~S3k5,~~ 100 V19 35,97
7u W%)
TOTAL (Also enter on Line 7, Recapitulation) $ Z,2 935, 9 /
If more space is needed, use additional sheets of paper of the same size.
REV-1511 EX+ (10-09)
10 pennsylvania SCHEDULE H
DEPARTMENT OF REVENUE FUNERAL EXPENSES AND
INHERITANCE TAX RETURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OF
FILE NUMBER
Han
Decedent's debts must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
polemw- ~401 Home ("#,l 1 011, 11,01610
Z~ Gin qnck - /1~ oriq~s ~~Cei q ac~e~ `]'10 DD
B. ADMINISTRATIVE COSTS:
1. Personal Representative Commissions:
Name(s) of Personal Representative(s)
Street Address
City State ZIP
Year(s) Commission Paid:
2. Attorney Fees: &fiei /l l ~ L&Isl 56 r~
3• Family Exemption:: (If dece~dlent's address is not the same as claimant's, attach explanation.)
Claimant
Street Address
City State ZIP
Relationship of Claimant to Decedent
4. Probate Fees: WlAU~ ~ly Isfeto~ ll~s (f~~~1) / JQ
5• Accountant Fees: X "~r^~ vet 3VO
6. Tax Return Preparer Fees: 5f TherMs U-~S`1 ~~Qvc `Qr~uJ~( reed 1`l t~ 1AA 00
7. pre~a6e2 le~t'sJ ~i (rr~s 0 60
A co~1s,~e` 'Ch V G~
e ood vd7),
WTMI:~14 ~4eM~ 2- ~ Z I -5,q
TOTAL (Also enter on Line 9, Recapitulation) $ 15 b4'~~ 8
If more space is needed, use additional sheets of paper of the same size.
REV-1512 EX+ (12-08)
i pennsylvania SCHEDULE I
DEPARTMENT OF REVENUE DEBTS OF DECEDENT,
INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS
RESIDENT DECEDENT
ESTATE OFTgOM4~ r(r` j yhljEy FILE NUMBER
2-1-12--0779
Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses.
ITEM VALUE AT DATE
NUMBER
DESCRIPTION OF DEATH
1, 1 ___T__
~.e I~rdr~IeOCn11111P (ji ' sf deck~ aft ~O.Sq
Z~ mov;0' 16SO A/vIr ~s~i{feme - ~ 30,00
y
M~lk
Ica ~x CXs
e(viC,e, C~l~ gee se ~e hi, ~~n Z l
3,e
P f 3 1
a- ed)
4 ~~sa6
~ y y ) lasq
°S~ovs ~5~ta~1.~ 5_3j12_
-51 amr)ed) 2-?6147
6, y 5,00
fS J'~~rCa ~ ~ ,
r~ Xarlw i 5g
g+ lie .O~e l/.Il
hVA'Ohj ~f f4 j5q I s r end n~ a e~) 5600
IA al
TOTAL (Also enter on Line 10, Recapitulation) $ SgOVI
If more space is needed, insert additional sheets of the same size.
REV-1513 EX+ (01-10)
pennsylvania SCHEDULE J
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN BENEFICIARIES
RESIDENT DECEDENT
ESTAT OF-
FILE NUMBER:
~61~5 R ILL 1-1 Z-0
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY RELATIONSHIP oNot List Trustee(s) NT AMOUNT ESTATE ARE
I TAXABLE DISTRIBUTIONS [Include outright spousal distributions and transfers under
Sec. 9116 (a) (1.2).]
1. fir, Suzanne D~~ &/9d 16066,0'0
2r David T (wMfe-r / CAW ZO fo ~
3f a~ A~ Phew ZD
C~llee~ el f1 me yon
4,
nod ~o*
5 Pae1a E( 1%D.(e<
J-t W la 1J r10AC z0
~ Q~ reside
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, AS APPROPRIATE.
II NON-TAXABLE DISTRIBUTIONS
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN:
1.
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS:
1.
TOTAL OF PART II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $
If more space is needed, use additional sheets of paper of the same size.
LAST WILL AND TESTAMENT 8/5/99
TR Haney
Being of sound mind, although there are those who would question this, I hereby leave
my stuff to various people.
My executors are my sister, Jeanne Marie Carpenter, and in her stead if necessary, nay
niece Pam Moser and Father Jim Lyons. (I'm figuring he'll still be around and perhaps on the
job). And also because he's a very dear friend.
For things that you need to find, check with my secretary Marge Trostle.
As of this date, (who knows I may go on a spending spree) I have money in PNC. about
$30,000. A savings account and checking.
I have money in Dauphin Deposit. A checking account as of'now about $9, 000.
1 have a life ins. policy with Penn Mutual at about $13,000. 1 was going to take out a
larger policy so that when I died, I'd have more. But
I have about $27,000 with Life USA.
All this can be found in the bottom drawer left side of my desk in my office at Dio
building.
Embarrassingly, I have to admit that I have nine or ten thou in cash in a tin box in the
table next to my chair at the rectory. (It was my way of giving the finger to the IRS).
I don't know if there'll be anything coming from Social Security. Check that.
If, for some miraculous reason, I have anything coming in from books, it goes into my
estate. (I had to use that word at least once).
As of this writing I don't have any outstanding bills except car payments.
Despite all this moola, I want the cheapest funeral possible. I don't care what corpse
house you use but don't let them smooth talk you into making sure I'm safe and comfortable. I'm
dead.
If Jeanne Marie is executor, all the money left over goes to her with the few exceptions
below. If not, then Pam should divide it up equally among my brother and my nieces and
nephews.
Jim, I'm leaving you all the quotations I gleaned over the years of reading. They're on
discs in a green disc box marked with your name. Also quotes from movies, TV and novels. You
can load them onto your computer if you want to. And you can share them as much as you desire
to do so.
There is a disc in another green disc box marked STORIES. This is for you and Suzanne.
Also a disc marked Humorous Stories for you, Jim and Today's Spirituality and Editorials for
Suzanne or anyone else, including you. It's in a thin disc box that's blue.
Also I put my novels on discs. They're in a yellow disc box marked, obviously, Novels.
Give these to Sr, Sarah Swayse and tell her to give them to Sr. Pam Smith and Suzanne after
she's loaded them or made copies thereof.
The as of now unpublished book, The Divine Indwelling, is on a disc. Give that to
Suzanne and tell her to share it with Sarah and whoever else (this includes you, Jim. You could
publish it under your own name - who'll know except Suzanne and Sarah; cut them in and
they'll keep quiet).
There's a disc entitled Meditations, Parables and Retelling the Jesus Story. "I his goes to
Suzanne and you can share it too. Tell Suzanne to share it with whomever.
These three boxes of discs are in the left top, big drawer of my desk in my office at the
dio.
Sister Suzanne Duzen gets the large carved plastic ornament with a black back on the top
shelf of my etagere in my room at the rectory and Sister Sarah Swayze, (275- 8590 private) gets
the smaller one.
The large cut glass decanter on my etagere goes to my niece Susan and the other one with
the four glasses goes to my niece Colleen. Pam gets the TV and VCR and my nephew David gets
the stereo.
The Hum.-eels on my etagere should go to my brother Gerard Haney in Phila. He lasts
after those Hummels.
But I want to leave one Hummel to the following, one Hummel a piece: Kucs (774-
2283), Cambrias (774-5133), they each get the larger Hummels, Sister Mary Beth (717-346-
8961). Donna Welborn (233-5510) and her goofy sister Beth, Colleen Attivo,( 939-2790),
Nancy Mikos (938-3718), Kathy Siegfied (938-6831), Mary Bluge (737-3297), Gloria
Dougherty in Palmyra (838-3887), Mary Ann Wayne (737-0685), Connie Mirando (774-3227)
and Marinella (938-3646).
Pat Reddy (540-8485 office) gets the table made out of cherry tree, next to my chair.
My music CDs are mostly classical. Divide them among Suzanne, Sara and Sr. Mary
Beth. There's also a handsome homemade tree table by my chair. You take that, Jim.
There are other things like some nice looking bookends. Give one set to Clem and Marie
Cicarrelli (774-5532) and another to Brenda and John Rossi (774-0353) ( remember him.?). Also
pick out some other things and give one to each person who worked with me in
Communications.
In my computer, under Fh, under Calls, you'll find these people's phone numbers.
(Women are more sentimental than men).
(Jim if you have to track down some of these people, at least that will give you something
worthwhile doing).
There are 18 Hummels so Gerard should have enough. Give him two thou because he'll
be unhappy that he didn't get all the Hummels.
If Gerard is not around, then Jeanne Marie or Pam can divvy the leftover Hummels and
others things up among the relatives.
Jeanne Marie or Pam, there are other trinkets or books to give to my grandnephews
nieces as dust-gathering mementos.
My books? I don't know what you want to do with them. It's a headache I'm leaving you.
Let Sister Suzanne pick out the ones that have stories. And, Jim, if you want any, help yourself.
I want to leave a thousand dollars to Sr. Suzanne for that trip she always bitched about
not having taken like all the other nuns in her community.
The furniture in my sitting room is all mine except the couch and the book case behind
the door.
I have, as of now, two Zip drive discs with all my writing stuff I've accumulated over the
years. They should bee somewhere around my computer in my office at the dio. They wont be.
hard to find since they have ZIP printed on them with computer contents #I and computer
contents 42. (One may be in my computer).
I want these to go to Alice Camille. Right now she's living at 2409 College Ave. #5
Berkeley CA 94764. Her phone number is 510-644-0501. God knows where she'll be unless I
push off tomorrow. Her parents live in Mt. Carmel. Their name is Perdegnana. ((570) 339-
1559. Alice changed here name when she became an author.
I have a Zip drive machine at home. Send that to Alice along with the discs.
Tell her that the novels on the disc go in this order: 1) Assault; 2) Idols; and 3) as of now
unnamed, called Book 3.
I also have CDs for the computer. Give them to Sr. Suzanne if she knows how to use
them or if she doesn't want them, give them to my niece Colleen.
I want all my handwritten notebooks to go to Sr. Suzanne. They're in my room at the
rectory.
You can throw all my medicine out. Apparently it didn't do me any good.
Jim, you make funeral arrangements. The parish where I am and in the priests' circle but
not near Bishop Schott. He never liked me. Have a lunch. That should bring the guys.
As for the homily, do what you want. Keep it light (people thought I was too intense and
somber except or Mitzel -xho said I was arroga.^t).
My clothes: let my nephew, Paul, take what he wants and give the rest to charity or some
priest who might be "hurting."
My car is leased. The lease ends with death. Take it back to Royer. The guy I dealt with
is Gary Young. You shouldn't have to pay anything. So don't let them bamboozle you.
Jim, I think you get a percentage. Check it out.
Well, by the time you read this, you'll know that I know.
God bless you all. (I had to get that word in too).
Jim, feel free to share this ponderous document with anyone who'd care to bother with it.
If there are any changes or additions or deletions (like somebody's no longer my friend)
you'll find a disc in the big drawer left hand side of my desk in my office in the diocesan center
marked ADD END ML .
Signed (legal name)
tmr 3 R .
Thomas R. Hane
u Y
LawpwrlwiTw COW*
S®rliafts C. U0010
HOLD DODUMEN UP C --HE -Iu `':EV r,..c WATFRM.ARP 3 'nwml-
HvLG GOOU6'cFl' UP TO THE LIGHT TO VMEVV TRUE WATERMARK
~ Bank ~~L erlECh
200297730-06
Manufacturers and Traders Trus: Company
BUFFALO N.Y 14240 10-4/220
CI 1-1
Hbi`i H--illt. f` DATE
REMITTEF
Back F
7 :
4Y TO THE ORDER OF E--Ti JE oF_ _n LIM7-1_ H !taC_f $ --r,
D~ ~ti_ ' I_!I_IF: NiJi•aL.~F:i-_i._ ;T', nd =1;_,~ ].[u:;e~':,..+.i i=~~~~: ~].i..=.,
TWO AUTHORIZED SIGNATURES REQUIRED FOR AMOUNTS $10,000.00 & OVER
AUTHORIZED SIGNATURE
AUTHORI EDSI NATURE
P 200 29 7 7 3D0 1:0 2 20000461: L 700 20 L99,260L. 7ll'
r
-9 5q3,
08M11 OUT 45ES ES12004208
ESTATE OF THOMAS R HANEY
PAMELA E MOSER, EXECUTRIX
204 PINE ST
STEELTON PA 17113-2347
PENN MUTUAL LIFE INSURANCE COMPANY OUT 08-27-2012 ES12004208 325 39625
THE ATTACHED CHECK # 1108723 FOR 19,653.95 REPRESENTS THE NET DEATH BENEFITS DUE
UNDER THE POLICY LISTED BELOW FOR REV THOMAS R HANEY.
CONTRACT NO. 004551723
DEATH BENEFIT 6;260.00
DEATH CLAIM DIVIDEND 23.77
DEATH CLAIM INTEREST 158.10
DIVIDENDS 13,192.55
DIVIDEND INTEREST 96.87
PREMIUM REFUND 24.65
POLICY LOAN -101.06
LOAN INTEREST CHARGE -0.93
CONTRACT PROCEEDS 19,653.95
TOTAL AVAILABLE AMOUNTS 19,755.94
TOTAL DEDUCTIONS -101.99
TOTAL CONTRACT PROCEEDS: CHECK ATTACHED 19,653.95
DETACH AND RFTAIN FOR YOUR RECORDS
METRO
888.937.0004
BANK mYmetrobank.com
Deposits may not be available for immediate withdrawal. For deposits made before 6:00 PM, that business day will be considered the day of your deposit.
Funds from vour cash and check deposits will be available to you on the first business day after the day we receive your deposit.
217 15:34 8/31/2012 2205 -8307
TIrDDDep $ 19,653.95
DERRY STREET STORE122
S-16
3MM V121NT
MEMBER T RONALD HANEY CHECK NO. 69-778578
CLAIMANT SELF DATE 10-16-12
POLICYHOLDER DIOCESE OF HARRISBURG AMOUNT $11,186.37
CLAIM NO H67724-1-XXXXXXXXX-911
LIFE TYPE OF BENEFIT PENDING DENIED PAYMENT
PROCEEDS
BASIC EMBER LIFE 11,160.26
INTEREST PAID 26.11
TOTALS 11,186.37
REMARKS
NOTICE: By endorsement of this check, the Payee certifies entitlement to this payment for benefits. This certification indicates that circumstances
affecting such entitlement have not changed and no false statements or misleading representations have been made in support of the claim for
payment. False representations could result in civil and criminal penalties including full reimbbrsement of benefits.
RETAIN FOR YOUR RECORDS
IF YOU HAVE ANY QUESTIONS - PLEASE CALL:
LIFE & DISABILITY CLAIMS
DES MOINES IOWA 50392-4650
LOCAL 1-800-245-1522
F097GC-5
0122853 STK 12 CLAIMANT:SELF 91133 MD
METRO BANK 888.937.0004
mymetrobank.com
Deposits may not be available for immediate withdrawal. For deposits made before 6:00 PM, that business day will be considered the day of your deposit.
Funds from vour cash and check deposits will be available to you on the first business day after the day we receive your deposit.
351 12:16 10/22/2012 2212 ***i'**830•
TIrDDDep $ 11,186.37
DERRY STREET STORE122
S-16
3MM 1112 lNT
Y 1 Ivv I tVL %J1 1 I\LI VII VIvI 1\LI Vt 14 IJ
DATE
MO. I DAY YR.
Erie 08 08 2012
Insurance
100 Erie !n;. PI Erie, Pa 16531 REFUND AMOUNT $ 401.00
POLICY/ACCOUNT NO. Q030804719
AGENT NO. AA7631
AGENT NAME CONSUMERS INSURANCE AGENCY INC
s~ CHECK NO. 2000444394
REFUND REASON PRO RATE CANCELLATION
000 0002512 00000000 001 00' 02542 INS: 0 0
ESTATE OF T RONALD HANEY AA7631 NON-NEGOTIABLE
C/O PAM MOSER EXECUTOR
204 PINE ST
STEELTON PA 17113
THIS REFUND CHECK HAS BEEN ISSUED TO YOU AS A RESULT OF
A PREMIUM CREDIT BALANCE REMAINING ON THE CANCELLED
POLICY/ACCOUNT INDICATED ON THE BELOW CHECK.
IF YOUR RECORDS DO NOT AGREE, PLEASE NOTIFY YOUR AGENT.
CH2751 v,08 5.4.2011
VOID 180 DAYS AFTER DATE
Eh e PAY PROTECTED Bank ofAmerIca Customer Connection 64-1278
E e Bank of Amenca, N.A.
~'!t\ Ins rance° Atlanta, Dekai6 County, Georgia 611
100 Erie Ins PI • Erie, PA 16530 DATE CHECK NO 2000444394
MO ! DAY YR.
PAY: EXACTLY FOUR HUNDRED ONE DOLLARS AND 00 CENTS: 08 08 2012
TO THE ORDER OF: ESTATE OF T RONALD HANEY $ 401.00
C/O PAM MOSER EXECUTOR
s
Sewnly feaNres
nrlWed
Delads on Datlc.
I
REFUND REASON POLICY/ACCOUNT NO AGENT NO. i
PRO RATE CANCELLATION Q030804719 AA7631
T
uthorized Signature" i
111 20004443940 1:0611127881: 32q 999 6S L40
HOBBIE AUCTIONS
901 North Second Street
Harrisburg, PA 17102
Phone: (717) 233 - 0115 Fax: (717) 230 - 8996
email: bii?,hobbieauctions.com
7/23/2012
Kenneth Lewis, Esq.
1101 North Front Street
Harrisburg, PA 17102
Dear Mr. Lewis:
Pursuant to your request, on July 7, 2012 1 did inspect items of the estate
of T. Ronald Haney located at 204 Pine Street, Steelton, PA 17113 as
designated by Ms. Pam Moser.
Having been an antique dealer for over 20 years and an auctioneer for 24
years, it is my opinion that the value for estate evaluation purposes of the
aforementioned items is as follows:
12 Goebel Hummels, some from West Germany,
some with chips, some dated 1999 and 2001 $420.00
Two pieces newer Wedgewood, vase and heart form dish $25.00
Pair white metal gold finish bookends $75.00
Pair duck form brass bookends, India $10.00
Juliet statue, pressed wood, Italy $35.00
Plastic diorama art: two pieces, mushroom and grass scene,
and bridge, lighthouse, and ship scene $40.00
Dell laptop computer, circa 2010 $200.00
Approximately 80 CD's, mostly classical music $40.00
Four boxes of longhand writing on notebooks and loose paper $-0-
Cherry stump table $45.00
2003 Buick Lucerne CXS, 10202 miles, maroon,
slight damage to body with upgrade power package $6,492.00
Sony flat screen 720 32" TV $100.00
TOTAL $7,482.00
Hoping this appraisal is helpful to you, I am glad to have been of service in
this matter.
As I look forward to working with you again in the future, please do not
hesitate to phone my office if you have any questions
Sincerely,
William W. Hobbie /
Hobbie Auctions
ST. THERESA'S CATHOLIC CHURCH 2831
GENERAL ACCOUNT r 60-184/313
1300 BRIDGE ST. l / z
NEW CUMBERLAND, PA 17070 DATE
r 1
PAY ,}Ij' I
TO THE
ORDER OF
I
METRO
8
BANK m etroban
vmetrobank.com
FOR YY n 4 i' .
D2
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f
II'00 2831u' 1:0 3 130 1846: 5 369 50 2801i■
AUTHORHOUSE c/o Content Distributors, Inc. Check Number: 341010
To: T. R. HANEY ID#: C-1082529 Date: 08/23/12
Date: Description: Paid Amount:
8/27/2012 02 2012 Royalties $16.24
Withholding; $6.31
Please join us in our effort to reduce paper waste AND
receive the benefit of direct deposit of your royalties. Visit
your online author account today to provide your electronic
banking information.
To avoid withholding on future royalty payments, please submit
a W-9 form with Tax ID Number to us at 1663 Liberty Drive,
Bloomington, IN 47403 or online via your secure author account.
~o
1:1 Lila: • •a•
D
AUTHORHOUSE c/o Content Distributors, Inc. JP Morgan Chase Bank, N.A. 341010
16,63 Liberty Drive` Indianapolis, IN
Bloomington, IN 47403 2011740
Pay SIXTEEN DOLLARS AND TWENTY FOUR CENTS 08/23/12 $16,24
Void After 90 Days
to the Order of.
T. R. HANEV
It' 3 4 LO L011' 1:0 7 40000 LOS: 9 3 7 5 2 5 2 5 LII'
METRO
BANK 888.937.0004
mymetroban
robank.com
Deposits may not be available for immediate withdrawal. For deposits made before 6:00 PM, that business day will be considered the day of your deposit.
Funds from your cash and check deposits will be available to you on the first business day after the day we receive your deposit.
111 12:15 9/1712012 1902 *''8307
TIrDDDe.p $ 16.24
UNION DEPOSIT ST0RE119
5-16
3MM 1,1z INIT
AU I HUHNUUSt C/o Uontent Uistrloutors, inc. Check Number: 383976
To: T. R. HANEY ID#: C-1082529 Date: 11129112
Date: Description: Paid Amount:
12/3/2012 032012 Royalties $1.75
WITHHOLDING: $4.18 '
Please join us in our effort to reduce paper waste AND
receive the benefit of direct deposit of your royalties. Visit
your Author Center page today to provide your electronic
banking information.
To avoid withholding on future royalty payments, please submit
a W-9 form with Tax ID Number to us at 1663 Liberty Drive,
Bloomington, IN 47403 or online via your secure Author Center
account.
AUTHORHOUSE C/O Content Distributors, Inc. JP: Morgan" Chase Bank, N.A. 383976
1663 Liberty Dr. Indianapolis, IN
Bloomington, IN 47403 20-1/740
Pay `TEN Dollars AND SEVENTY FIVE Cents 11129/12 $10-75
Void After 90 Davs
to the Order o`:
T. R.HANEY 1
- -
ll' 3 8 3 9? Ell' 1:0 7 4 0 00 0 10 1: 9 3 7 5 2 5 2 5 Lu'
FREDERICK CLAIMS ADMINISTRATOR
P.O. BOX 2374
FARIBAULT. MN 55021-9074
111111 IIIII IIIII IIIN IIIII illl{IIIII III{I IIIiI llili 1111 111111 illll 11111 11111 11111 illll 1111 1111
0002547923 164791 0841711
PRESORTED
T R HANEY
1300 BRIDGE ST
NEW CUMBERLAND PA 17070-1 115
Regarding Frederick v. FIA Card Services, N.A. and Augustine v. FIA Card Services, N.A.
Dear T R HANFV:
Attached is a check for your portion of the Frederick, et aL v. FIA Card Services, et aL and Augustine v. FIA Card Services
Settlement.
Please detach, sign and cash this check immediately. This check is subject to the terms and conditions of the Settlement, which are
available through the Settlement Website at www.FrederickAdministrator.com. If this check is not cashed within 120 days from
the date on the check, it will become null and void and will not be replaced. By signing and cashing this check, you are not signing
up for any product or service.
Refer to the Settlement website at www.FrederickAdministrator.com for more information regarding the Settlement, as well as for
the terms and conditions of the Settlement and a copy of the Settlement Agreement.
PLEASE KEEP THIS PAYMENT STUB FOR YOUR RECORDS
Check Number Description Amount
164791 Frederick v. FIA Card Services $2.45
~GIM14111111111 .
Detach and sign the back of this instrument.
FREDERICK CLAIMS ADMINISTRATOR bank- 37304 164791
P.O. BOX 2374 '400
FARIBAULT, MN 55021-9074
Date Control Number Amount
I
01/08/2013 0002547923 $2.45
VOID AFTER 120 DAYS
NOT VALID FOR AMOUNT OTHER THAN $2.45
Payee's signature required on back in order for this payment to be valid.
Pay: TWO DOLLARS AND FORTY FIVE CENTS
Payable to: T R HANEY j
y n~ ~
Authorized Signature
M012 IN 1A914140P) 1:4,11 • • . •
.•nosnnnC1_C: I• 14C.L4Lg7L.AL, 111'
ODD FELLOWS HOME 2381
OF PENNSYLVANIA, INC.
03-50/310
RESIDENT TRUST FUND BRANCH 88382
999 W HARRISBURG PIKE IJ
MIDDLETOWN, PA 17057-4801 DATE l n f j
PAY
RDER OF
1~ i n 1 -U j
WA,CHOVIA
Wactmia Bank, a division of Wolfs Fargo Bank. N.A.
FOR (Cv~J
111002-181113 1:0 3 L000 50 31: 200060 L L 4 5 36 2 11'
1MVESTMENTS
atholic Diocese of Harrisburg
401(k) Retirement Savings Plan November 27, 2012
Important Distribution Information
403B 57506 Please verify your transaction for accuracy,
PAMELA E MOS ER any discrepancies within 30 days. Discuss the tax bilityoof
204 PINE STREET this distribution with your tax advisor.
STEELTON, PA 17113
O web: www.fidelity.com/atwork
Phone: 1-800-343-0860
Hours: Weekda s 8:00 a.m. - Midnight ET
Important Information on Reviewing This Distribution Statement
The following is a summary of a death benefit distribution processed from your account.
Please keep this report until you receive a tax form in January of next year. Remember to keep your address up-to-date.
Distribution Summary
Below is your total account balance after your withdrawal. Please verify the information for accuracy.
Beginning Balance $22.835.87
Less Withdrawal -22,835.87
Ending Balance $0.00
Tax Information
Please verify the information for accuracy,
at
Total Distribution
Total Taxable Amount $22,835.87
Ordinary Income Amount $22,835.87
$22,835.87
Check Information
Please verify the actual information agrees with this.
PAMELA E MOSER Check Date: 11/27/2012
204 PINE STREET Check Number: 253844300 Gross Amount
STEELTON
, PA 17113 Federal Tax $22,835.87
Net Amount 18,567.17
$18,268.70
Fidelity Investments, P.0 Box 770002, Cincinnati. OH 45277-0090
Confidential Information
Page 1 of 2
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Gingrich Memorials
568 N. Union Street
Middletown, PA 17057
(717) 944-3441
Pam Moser znVo/Ce 9/5/2012
204 Pine St
Steelton, PA 17113
Contract# Contract Date Name Salesman
1-01796 8/1/2012 Ronald Haney Nathan Gingrich
1
1 Grass Marker
1 Foundation
q ank you, your memorial or cemetery Order Total: $770.00
MSCfVt'><M isfittisfwd Payments: $770.00
Balance Due: $0.00
Please include contract # with your payment
A finance charge of I V2% per month (I8% annually) will be added after 30 days
PLEASE TEAR THIS PORTION OFF AND RETURN WITH PAYMENT
Ginqrich Memorials Family: Haney
568 N. Union Street Contract#: 1-01796
Middletown, PA 17057
Balance Due: $0.00 Amount Paid:
RECEIPT FOR PAYMENT * DUPLICATE
GLENDA FARNER STRASBAUGH Receipt Date: 7/23/2012
Cumberland County - Register Of Wills Receipt Time: 09:52:31
One Courthouse Square Receipt No.: 1070708
Carlisle, PA 17613
HANEY THOMAS R
Estate File No.: 2012-00797
Paid By Remarks: PAMELA E MOSER
HEA
Receipt Distribution
Fee/Tax Description Payment Amount Payee Name
RENUNCIATION 5.00 CUMBERLAND COUNTY GENERAL FU
PETITION LTRS TEST 90.00 CUMBERLAND COUNTY GENERAL FU
WILL 15.00 CUMBERLAND COUNTY GENERAL FU
SHORT CERTIFICATE 32.00 CUMBERLAND COUNTY GENERAL FU
JCS FEE 23.50 BUREAU OF RECEIPTS & CNTR M.
AUTOMATION FEE 5.00 CUMBERLAND COUNTY GENERAL FU
Check# 7019 $170.50
Total Received......... $170.50
_~F+%DUL 1~ll~Cf}S
THE MIDDLETO lei W HOME
An Odd Fellows Home of Pennsylvania
Courtyard Gardens Nursing & Rehabilitation Center
Crescent View Personal Care West View Terrace Apartments
08/17/2012
T Ronald Haney
C/O Mon. James Lyons
Prince Of Peace Parish
Steelton, PA 17113
RE: Payment Reminder Notice 9. S 9
Dear Mon. James Lyons
This is a reminder notice that the payment due on T Ronald Haney account
has not been received. Our payment terms are due upon receipt. Please
remit promptly.
If payment has been sent, please disregard this statement.
~
Sincerely, PV!7
Teresa M. Crnjar-Pully
Billing Specialist
(717) 944-3351, Ext 4124
FtTNOWBAMINY bTVMV4 EEC
*LTON, IA 17113 7 a
$ 5-9
N _uoLtti 8
1QTRO
BANK
L1:031301 64 2843268307 0506
#506 20120830 $4,409.59
999 West Harrisburg Pike
Middletown, PA 17057
htto://win,v~.middletownhome org
ease remember us in your giving
MARIA JOSEPH MANOR
875 MONTOUR BLVD
DANVILLE, PA 17821-9135 Statement Date 07/31/2012
(570)275-4221
Services Provided For:
ANEY, THOMAS RONALD 1612
FR JAMES LYONS Admitted: 05/22/2012 Discharged: 06/16/2012
5505 GRANDVIEW ROAD
HANOVER, PA 17331 Pay this Amount: 30.00
Make checks payable MARIA JOSEPH MANOR
HANEY, THOMAS RONALD 1612 Statement Date 07/31/2012
Date Description of Service Current Balance
07/01/12 BALANCE FORWARD 30.00
BALANCE DUE 30.00
3
EsTwTE W THOU" R HANEY a -ta - 503
0-= L NOW, EXEC VJL
a" ME ST
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a
8T!lLTt7N. DA 17113
i~~ $ 0
BANK
1:03130 18 1s 28 4 3 268 307r 0503 r
#503 20120815 $30.00
- Medical Express Ambulance Service Inc
Billing Office 12-145386 10/8/2012 7$7205.44
PO Box 726
New Cumberland, PA 17070-0726
QUESTIONS ABOUT THIS BILL? Phone: 877-214-6018 tspanol 866-724-4114 Fax: 717-214-6020 Email: info@ambulancebillingoffice.com
Date of Service: 5/2/2012 07:52 Please visit our website to provide insurance or make payment, and
Patient Name: HANEY, THOMAS R. for additional payment options and frequently asked questions:
From: MIDDLETOWN HOME www.ambulancebillingoffice.com
To: Harrisburg Hospital (Pinnacle)
IMPORTANT MESSAGE:
***YOUR ACCOUNT IS PASTDUE*** This claim will be submitted to a third-party collection agency ifpayment is not
received within 10 days. You will be responsible for all collection fees incurred. NONPAYMENTMAYAFFECT YOUR
CREDIT
40 Y-i
- 10- WIN
5/02/12 BLS Non-Emergency Transport A0428 1.0 500.00 500.00
5/02/12 Mileage A0425 17.7 10.75 190.28
5/02/12 Adjustment - Insurance -363.67
6/13/12 Adjustment - Insurance 5.37
6/13/12 Payment -126.54
Total 690.28 -358.30 -126.54
lETAT! OF TIKOMAS R NARY 520
►AIMA I- YOtER,
aDE PIKE ST .►lrou
STEELTON, PA 17113
IAY IO TIE~~ ~(J 1 ~ ~~~f U~
/~.Fjfd,W/~pCr d- ~ nolu.s 8
lI~ETRO r
BANK
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1:0313D18L.S1: 286326830710 0520
#520 20121105 $205.44
t NOW or ~z
%1b11. PA 171 to N 5
OF DAIS
BANK
x:03 i30 i846~: 284j e68307r
0504
X504
20120817 $76.74
i~
Please Remit Payment To:
Medical Express Ambulance Service Inc
Billing office 1 12-147888 1/17/2013 $38.93
PO Box 726
New Cumberland, PA 17070-0726
QUESTIONS ABOUT THIS BILL? Phone: 877-214-6018 Espanol: 866-724-4114 Fax: 717-214-6020 Email: info@ambulancebillingoffice.com
Date of Service: 5/8/2012 13:57 Please visit our website to provide insurance or make payment, and
Patient Name: HANEY, T R for additional payment options and frequently asked questions:
From: HERSHEY MEDICAL CENTER www.ambulancebillingoffice.com
To: MIDDLETOWN HOME
•
This account is Past Due *Your account remains unpaid despite our previous billing requests. Your
account is now under collection review and may be forwarded to our collection agency if this bill remains unresolved.
5/08/12 Invalid Coach Trans - One Way A0130 1.0 100.00 100.00
5/08/12 Mileage (loaded) S0209 7.4 5.00 37.00
11/27/12 Adjustment - Insurance -59.15
11/27/12 Payment
-38.92
Total 137.00 -59.15
-38.92
DETACH AND RETURN BOTTOM PORTION WITH YOUR PAYMENT.
TEELTON BRANCH USPS
EELTON, Pennsylvania STEELTON BRANCH USPS
171139998 STEELTON BRANCH USPS STEELTON, Pennsylvania
4134870111 -0097 STEELTON, Pennsylvania 171139998
(800)275-8777 02:48:03 PM 171139998 4134870111 -0097
4134870111 -0097 09/10/2012 (800)275-8777 02:38:25 PM
- Sales Receipt 09/10/2012 (800)275-8777 02:52:55 PM
Sale Unit Final Sales Receipt
Qty Price Price Sales Receipt Product Sale Unit Final
Product Sale Unit Final Description Oty Price Price
7319 Zone-1 $2.97 Description Qty Price Price
Parcel NEW ROCHELLE NY 10805 $3.48
HARRISBURG PA 17104 $5.75 Zone-2 First-Class
Zone-0 Parcel Post Parcel
$2.97 2 lb. 13.30 oz. 11.10 oz.
A 17011 $5.30 Issue PVI: $5.75 Issue PVI: $3.48
r 2. Mail BERKELEY CA 94704 CAMP HILL PA 17011
oz. Zone-8 Parcel Post $12.09 2one-1 Priority Mail $5.30
$5.30 3 lb. 14.90 oz. 1 lb. 0.50 oz.
'A 17011 $5.30 Issue PVI: $12.09 Issue PVI: $5.30
,rity Mail
i OZ. NEW CUMBERLAND PA 17070 $8.46
- Total: $17 1 Zone-1 Parcel Post
$5.30 Paid by: 6 lb. 9.80 oz.
.AND PA 17070 $5,30 VISA l $17.84 j Issue PVI: $8.46
irity Mail Account XXXXXXXXXXXX~4,~~-
oz. Approval 624980 HARRISBURG PA 17113 $3.14
Transaction 252 Zone-0 First-Class
$5.30 23 903110203 Parcel
9.70 oz.
.AND PA 17070 $3.65 Order stamps at usps.com/shop or call
:t-Class 1-800-Stamp24. Go to usps.com/clicknship Issue PVI: $3_14
to print shipping labels with postage. 10805
For other information call 1-800-ASK-6SPS. NEW ROCHEL NY ail $5.30
*xxxxxxxxxxxxxxxx*x**********x*x**xxxxxx Zone-2 Prior rity Mal
$3.65 *x******xxxxxxxxxx**xx*x**xxxxxx*xxxxxxx 1 lb. 1.50 oz.
Get your mail when and where you want it
17078 Zone-1 $2.97 with a secure Post Office Box. Sign up for Issue PVI: $5.30
Parcel a box online at usps.com/poboxes.
************xx*****x*xx**x*xxxxxxxxxxxxx NEW ROCHELLE NY 10805 $8,01
x**x****x*******x****xxxx*xxxxxxxxxxzxxx Zone-2 Parcei Post
$2 97 5 lb. 12.80 oz.
.7319 Zone-1 $5.30 Bill#: 1000301998042 Issue PVI: $8.01
iil Clerk: 02
oz.
_ All sales final on stamps and postage Total: $33.69
$5.30 Refunds for guaranteed services only
Thank you for your business Paid by:
.AND PA 17070 $5.20 x***xx****x**xxx***z%**xx*******xxxxxxxx VISA $33.69
)rlty Mail *********************x*zx***xx*xzxxxxxxx Account XXXXXXXXXXXX
HELP US SERVE YOU BETTER Approval 681987
Transaction 250
$5 20 Go to: https://postal experience.com/Pos 23 903110203
.AND PA 17070 $6.17 TELL US ABOUT YOUR RECENT Order stamps at usps.com/shop or call
;el Post POSTAL EXPERIENCE 1-800-Stamp24. Go to usps.com/clicknship
l oz. to print shipping labels with postage.
YOUR OPINION COUNTS For other information call 1-800-ASK-USPS.
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)203 Clerk: 02
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SWATARA BRANCH
HARRISBURG, PennsvIvanla
171119998
4134870108 -0099
07/26/2012 (800)275-8777 12:14:1? PM
Sales Receipt -
Product Sale Unit Final
Description Qty Price Price
MINNEAPOLIS MN 55459 $C.65
Zone-5 First-Class
Letter
1.40 oz.
Expected Delivery: Mon 07/30/12
Return Rcpt (Green .;ard) $2.35
Certified $2,95
Label 70112970000313102919
Issue PVI: $5 95
CINCINNATI OH 45277 $0.65
2one-4 First-Class
Letter
1.40 oz.
Expected Delivery: Mon 07/30/,2
Return Rcpt (Green Card) $2.35
Certified $2.95
Label 70112970000313102au2
Issue PVI: $5. 95
(Forever) 40 $0.45 $18.00
Bicycling
PSA
Total: $29.90
~i
Paid by:
Cash
Change Due: -$10.10
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1-800-Stamp24. Go to usps.com/clicknsln p
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Clerk: 12
All sales final on stamps and postage
Refunds for guaranteed services orlti
Thank you for your business
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Qcomcast'
Account Number 09547 445043-0 1-4
Billing Date 05/28!12
Total Amount Due $276.47
Payment Due by 06/25/12
Page 1 of 2
Contact us: www.corncast.com , 717-540-8900
RONALD HANEY
Previous Balance 165.95
For service at: Payment- 05/07/12- thank you 999 W HARRISBURG PIKE APT 139 Y -165.95
MIDDLETOWN PA 17057 New Charges - see below 276.47
Total Amount Due $276.47
News from Comcasi Payment Due by 06/25/12
Thank you for your prompt payment.
For your convenience, we now accept regular and XFINITY TV 251.26
automatic monthly credit card payments and direct
debit. Taxes, Surcharges & Fees 2521
o
Hearing/Speech Impaired Cali 711 Total New Charges $276.47.'
GE S LAAugust 12, 2
D 0 o H CADEMYAVENUE Billin ' 012 Medical Record
VILE, 17822-3941 g Statement Number: 00419600
for Thomas R Haney Page 1 of 2
To view your bill online 32283
~_orq/nav6ill
go to www.geisinaer IIIII~IIIIhIIIII~IIVIIII~IIIIIIIn~II~IA~NHIq~p191~I~N~II
This billing statement represents physician charges for Patient: Thomas R Haney
Geisinger Clinic. Medical Record Number: 00419600
Insurance Provider: FreedomBlue PPO
Policy No: FER105100102001
How to reach us
• Requests for an appointment? Previous Charges: $5.00; Due Immediately
1-800-275-6401, 7:00 AM to 9:00 PM, 7 days a week
• For billing questions, change in insurance coverage, or New Charges: $0.00
questions regarding your deductible, copays, or coinsurance,
please contact our Patient Service Call Center at What you now owe: $5.00
1-800-640-4206, 7:30am to 6pm M-F, gam to 1 pm Sat.
• E-mail; GHSPatientServiceCallCenter eisin er.edu. We What you need to do
do not recommend sending confidential information to this
address, as it is not secure (encrypted). Our MyGeisinger 1 Your account is now past due. You are responsible for
Program, available at hts:#rn eisinQer~eisin_ o rg
payment in.full. Please pay the balance due.
offers a secure alternative. er.o
2. To pay your bill, you can
• Written Correspondence? 1) go to www.geisingerwebpay.org1
G
-640- or
100 eisinger Health System Patient Service 3) Return the invoice below witei North Academy Avenue, Danville, PA 17822-4322 2) call the PSCC at 1-80ow with4206,
payment.
(Please see reverse side for check conversion process)
""Geisinger" and "Geisinger Health System" are trademarks of Geisinger Clinic. As a convenience to you, we will accept one Payment made out to
any questions.
Geisinger Health System, and we will distribute the payment to the appropriate entities that provided care to you as detailed in this statement. PI
ease contact us with
Detach and return bottom portionwith payment. Please make checks payable to Geisinger Health System, and write our
32283*TKLOMJK3DO03709
Y medical record number on the check.
IF PRYING BY MASTERCARD, DISCOVER. VISA O 6..2'100 (P,:2:
R AMERICAN EXPRESS, F
CARD USING FOR PAYMENT ILL OUT BELOW.
ul
GEISINGER VISA
MASTERCARC' ® DISCOVEP.-I nSA
100 NORTH ACADEMY AVENUE CARD NUMBER MOM AMERICAN EXPRESS
DANVILLE, PA 17822.3941 'SIGNATURE co DE
SIGNATURE
EXP. DATE ~
'Signature Code is the 3-digit code located in the signatureatrig on. the backof card. _
Patient: Thomas R Haney
Medical Record Number: 00419600 Statement Date. August 12, 2012
Previous Charges: $5.00; Due Immediately
What you now owe: $5.00
New Address? Check here and write your new address on the back ;_i
Amount Enclosed:
)202
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T
HOMAS
THOMAS R HANEY IIII I I.,Illllflllltllllll'II(IIIEI"lla~ll't"II'I" ~(I:,.(,II,~,J~IrI,
SCHOOLHOUSE RD GEISINGER HEALTH 'SYSTEM
600 P.O.
DANVILLE, PA 17821-7200 NEWARK BOX 27727
, NJ 07101-7727
0027727 00419600 00000000 1000000006000005002 081222 0 002 7
KEYSTONE PROFESSIONAL PHARMACY 32 EMMANUEL CTR. NSG.&REHAB
PO BOX 659 ;t-tube L,
WILKES BARRE PA 18703-0659 ' 1344
(570)970-2200 v 08
(877)970-2200
$411.58
4T~otin tee' /02/12
ar>
HANEY,RONALD T.
C/O JAMES LYONS
815 SOUTH SECOND STREET
PRINCE OF PEACE
STELLTON, PA 17113 Xv
Please detach here and return to
with your
payment
1344
08/0,V12 KEYSTONE PROFESSIONAL PHARMA 32 PO BOX 659
WILKES BARRE, PA 18703-0659
GUANTR (570)970-2200
Balance Forward
(877)970-2200
New Activity (Continued)
$0.00
05/22112 269150 k
BURKE,GR£G NDC: 00597007541
05/22/12 269282 BURKE,GREG JANTOVEN TAB 1MG
NDC: 00832121100 1 c
DOCUSATE SODIUM (DOK) 100MG $4.34
05/22/12 269363 BURKE,GREG NDC: 00904788980
BUSPIRONE T 28 $3.45
05/22/12 269365 BURKE,GREG NDC: 0009310015MG
CARVEDILOL TAB 3.125MG 28 c $9.54
05/22/12 269366 BURKE,GREG NDC: 68382009205
GA13APENTIN CAP 300MG 28 c $8.93
05122112 269873 BURKE,GREG NDC: 53746010205
ACETAMINOPHEN 42 c $10.61
05/221,2 269983 BURKE,GREG NDC: Q0904198280~APAP) 325MG
MILK OF, N ^,AGSLIS I 30 $3.36
05/22/12 270021 BURKE,GREG NDC: 00904078814
BISACODYL SUP 355 $5.62
05/22/12 272061 BURKE,GREG NDC: 00.574 ()M(3
3 $3.32
05/24/12 276349 BURKE,GREG GA13APEN71N CAP 100MG
NDC:5374601o105 3 c
JANTOVEN TAB 1 MG $4.45
05/25/12 278076 BURKE,GREG NDC: 00832121100
SILVER SULFA CRE 1% 3 c $5.01
05125/12 278077 BURKE, NDC: 00591081055
_ 50 c $7.5p
05/29/12 2$7742 EE2TAr6 o f ,,"o,.AS R "NEY
B URKE f
,G ' ELA E. MOSER. EXEC 07-12' 30 c $15.00
2'04 MNF gT SOS
STMTON. PA 17113
continued on next page a 1 c $4.34
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Estate of T Ronald Haney
Appraisal of contents and auto
$750.00
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